What is Medical Quality?

The most prestigious Boston hospitals are paid 15-60% more per procedure, but are not especially healthier:

Call it the best-kept secret in Massachusetts medicine: Health insurance companies pay a handful of hospitals far more for the same work even when there is no evidence that the higher-priced care produces healthier patients. …

Brigham, Mass. General, Children's Hospital, and a few others are, on average, paid about 15 percent to 60 percent more than their rivals by insurance companies … The hospitals that are paid at the highest rates … have the bargaining clout to demand higher insurance payments. Often, that clout is based on a powerful brand name and elite reputation. … Insurers pay to keep Children's happy because they know parents won't buy insurance that doesn't include access to one of the world's most prominent pediatric hospitals. … One influential researcher found that Beth Israel's overall mortality rate was lower in 2005 than the mortality rates at both the Brigham and Mass. General, but the hospital and its doctors still earn 15 percent to 20 percent less for the same work. …

Karen Dahl, 31, lives less than 2 miles from Mount Auburn Hospital in Cambridge, but when she became pregnant with her first baby last year, she decided to go to a Boston teaching hospital to deliver. "I talked to women in the area who had babies in Boston," said Dahl, … "I also looked at the US News rankings for female care. The Brigham was rated very high." State health officials have tried to encourage women like Dahl to reconsider their flight to Boston, pointing out in a 2003 study that community hospitals are generally just as reliable as teaching hospitals for normal births. In fact, they had a slightly lower complication rate – and they're a lot cheaper. … But Dahl, who had a complicated pregnancy, has no regrets: "I felt this was the safest place to be if anything happens." Massachusetts patients love brand name medicine, going to teaching hospitals 2.5 times more often than patients across the country, according to a 2005 report …

A review of 42 individual mortality ratings produced by the state and federal governments for Massachusetts hospitals from 2002 to 2007 found that … the Brigham ranks high, though not among the very best; Mass. General was part of the broad middle, or average, tier. Partners officials said … the statistical methods used to adjust for the sickness of the patients at different hospitals are not sophisticated enough to recognize how much more vulnerable their patients are.

I doubt demand for these hospitals has decreased since this article appeared in November. Nor do I think other cities' newspapers are eager to write similar articles; readers just don't seem much interested. Why?

I suspect patient demand for prestigious docs has little to do with evidence about their health effects, and I doubt most patients have better evidence than that discussed in this article. Yes patients want prestigious docs and hospitals, and they may believe that high status docs are healthier, but I doubt that belief causes their demand; causation most likely goes the other way.

The simplest explanation seems to me sufficient: people just prefer to affiliate with high status others. High status hospitals have docs from high status schools, publishing in high status journals, with high status equipment. So patients gain in status by affiliating with them. As long as high status docs aren't a lot less healthy, patients don't care much about how healthy they are.

Added: Perhaps only randomized experiments could really tell hospital quality differences. Did this article inspire concerned citizens to organize to demand such experiments? No, they'd probably object that randomly sending high status patients to low status hospitals violates their ethical rights to work the system to avoid the low status docs that ignorant low status patients accept.

You make a good point, Robin_Hanson, but what about the role of psychosomatic effects? Since a patient’s optimism and expectations can influence the outcome (e.g. the placebo effect and the effect of perceived hopelessness), couldn’t the patients at the high-status hospital be getting better results than if they had to go to hospital of which they had lower expectations? Is it possible to call out the Emperor’s new clothes without worsening average outcomes?

burger flipper

I just switched between medical groups in my HMO in L.A. from one where my wife would deliver our first child in a hospital thats site boasts of a new coat of paint and the addition of a feedback/comment box to the maternity ward, to a group in Beverly Hills that most people would recognize by name from stories about Hollywood stars’ ailments.

This change was spurred by Internet reviews and our experience at the first group’s GP (2 hr wait/sole whites in the waiting room/office receptionist invisible and un-summonable behind frosted glass/office hawking a line of creams, poultice’s, etc). In Bev. Hills, the OB office (of an HMO group)is bright, cheery, efficient, and has a high-tech veneer).

I was initially shocked to be relegated to the first, and then after seeing the first, I was surprised I had access to the 2nd (we cannot switch to PPO until after the baby) even with a 30 minute drive.

I don’t know what objective statistical difference it would take for me (and more important, the missus)to switch back.

But now I will at least do a little research. (any suggestions where to look, Retired Urologist?)

“When you go to a teaching hospital you have residents and interns caring for you, which is different from our hospital,” said Dr. Richard Zelman, the hospital’s director of interventional cardiology, referring to doctors who have not completed medical training. “When you come into Cape Cod Hospital at three in the morning having a heart attack, you have an attending cardiologist with 20 years of experience that will take care of the patient every step of the way.”

I’m not confident that the public is aware of the system used for distributing responsibilities for patient care, and more importantly, patient treatment decisions, at teaching hospitals (which tends to be what is meant by “prestigious hospitals” and “prestigious docs”). Both the first-line doctors and the first-line nurses usually are students in training, as are many of the technicians. The professors (the legal attending physicians) are far less a presence after normal hours. In my experience, the perceived ability of the house officer to handle complicated problems rises dramatically after dark. (N.B.: the TV heroes, Ben Casey and Dr. Kildare, were both house officers in training, yet presented to the viewing public as if they were the ultimate docs medicine had to offer.) Many night-time surgical procedures and interventional measures occur without the presence of even a board-eligible doctor, much less a “prestigious doc”. The first call from the nurses (who themselves may be in training) almost always goes to the intern or 1st-year resident in pre-fellowship specialties (medicine, ob-gyn, pediatrics, general surgery, urology, orthopedics, etc.), and frequently likewise in the fellowship sub-specialties, or otherwise to the first-year fellow. It is commonly considered a cop-out for this person to call those above him.

Teaching hospitals frequently spend money on complicated equipment that would not be used with enough frequency at a community hospital to justify its cost, and they frequently offer otherwise unavailable teams for managing unusual or exceptionally time-consuming problems. The same is true of much investigational treatment. There can be little comparison with community hospitals in these areas, since the services usually do not overlap.

My guess is that the increased prices at the teaching hospitals reflect their inefficiency and increased overhead. The patient and his insurance company are paying for the education of tomorrow’s independent healthcare providers. I don’t have a suggestion for how to get around this. In my state, the best results for surgical cardiovascular healthcare, and the lowest expense for producing those results, is provided by a private, for-profit, doctor-owned facility with no teaching or research agenda. But the personnel who provide that care came from teaching facilities such as described.

Robin, a “status” explanation sounds like a bias from academia, a world that insiders say is populated by people who focus on status.

Another guess: Brand-name hospitals are less likely to leave a sponge in or take off the wrong leg. And if they do something inept, they are more likely to reach in to deeper pockets to preserve their brand than No-Name Municipal Hospital. Whether all that is true or not is another question. But, it’s what the customer would expect, eh?

Explanation 2: Something strange is going on with the sector – e.g., there is massive government interference in medicine.

We already know that Explanation 2 holds. Explanation 1 may be superfluous.

I can imagine the following reply: “I have already taken into account government intervention, and people still are making choices very different from what we might have expected.” To which my answer is: I’m not so sure it’s that easy to take government intervention into account, to foresee and accommodate all its effects.

frelkins

The key in the quoted piece is that the mother-to-be “talked to women who had their babies in Boston,” that is, her somewhat wealthier friends. I see this in my nabe all the time, although here of course no one admits to going to the hospital – you have to have the celebrity mid-wife and doula who delivered Starlet X’s kid by Pretty Boy Y. And you must have a real English nanny from The Upper East Side Nanny Agency.

It’s not only that you feel as if you get better care from a higher-status authority, but that the entire child-having process now is as completely status-ridden as buying a car. The child from conception onward is just an object on which to hang your wealth signals via various accessories, from the doula to the stroller to the designer organic Japanese baby clothing to the US$15K kindergarten.

Cyan

Constant,

Explanation 1 is a causal explanation. Explanation 2 basically asserts that Distortion A causes Distortion B with no description of the actual causal mechanism. Even if it’s correct, it doesn’t actually explain anything until more detail is provided.

Nurse

That Boston article was a bit too conspiracy theorist in tone and overlooked several factors that lessened the credibility of its claims. There was no comparatives of the acuity levels of patients, regardless of whether they’re receiving the same procedures. Tertiary centers often get patients of higher acuity than would go to smaller community hospitals — that alone could credibly explain some of the differences in costs, as well as the “worse” outcomes. But without controlling for acuity, no one can credibly compare hospitals. There were no comparatives for the experience and training levels of staff. There was also no consideration for the percentage of free care provided and larger regional centers also often provide more free care for indigent populations, which raises their overhead for the rest of their patient population. This story didn’t provide sufficient detail or balance to allow for any credible conclusions.

Douglas Knight

No one ever got fired for buying IBM.

It’s a subtle distinction, but I don’t think the patients want status as an end in itself, just that they are much better at judging status than directly judging quality. They occasionally hear isolated claims that lower status hospitals are better, but they are probably suspicious of concentrated claims. Can you trust it? Can you trust yourself to unpack the details and make sure it is judging exactly the quality you’re looking for?

Nurse, did you read any of the studies the paper refers to, or are you just reacting to the newspaper article? Academic studies usually try to control for severity of patient condition.

Constant, your theory that everything government touches is “strange” seems too weak to be of much use. The theory that people seek connections with high status people leads to lots of concrete expectations.

Robin — have you noticed that observational studies in medicine are often overturned by randomized controlled trials? Its not because the observational studies didn’t employ the fanciest techniques in statistics to control for disease stage or acuity — its because the techniques we have for measuring this stuff just aren’t accurate enough.

I know economists believe they can control for confounding — it just amuses me how they ignore the ridiculous number of well conducted large observational studies that have been overturned. I’m sure you plan on contrasting the level of evidence in Medicine vs. Economics at one point.

Patients might be matched on 5 variables — but any one of 100 to 500 other features might obviously indicate to any health care professional that one patient is much, much sicker than the other. Anyone who has ever taken care of a person who is sick or talked with someone who has knows this.

The absolute sickest patients are the ones transferred to tertiary care centers. This is the way those hospitals work. It doesn’t matter what you control for — its just gonna be absolutely MEANINGLESS. Garbage in, garbage out.

My one quibble is to question how much status people actually gain by going to certain hospitals. I’ve heard that some chimpanzees are willing to “pay” to be able to look at high-status chimps. I don’t think looking actually raises their status though.

Diogenese, if even the best research can’t disentangle these effects, what basis does the average patient have for believing prestigious hospitals are more healthy?

Nazgul, this hypothesis predicts education will have little effect.

frelkins

@Robin

“this hypothesis predicts education will have little effect”

Indeed, only increasing the status of the actually safer and cheaper community hospital will work, it seems. Considering the enormous difference in medical prices between the high-status and lower-status hospital, this should turns out to be a strangely urgent piece of health care policy.

How to increase the status of the community hospital – have the city or state give out awards to place on the hospital’s website? Have the hospital run ads announcing these awards? Run ads highlighting its most accomplished doctors and telling success stories? Painting the rooms is more fashionable colors and upgrading the decor?

Robin — doctors at the academic hospitals — especially top hospitals — are often super-super-super specialized. It is economically inefficient, but it lets 1 person become an expert on a particular disease, surgery, or procedure, and to study and try and advance it. If you’re a healthy 35 year old or have a common disease, the benefit is probably non-existent to marginal. However if you have a rare disease, that most physicians only see 1 or 2 in their careers, you’d probably be better off going to an academic center where someone has seen 100 patients just like you. Similarly if you have a common disease that has done something peculiar, at an academic center, there will be someone who is familiar with it.

@retired urologist: I think the quality of care you can receive for common interventional procedures is probably equivalent at top community centers (maybe even superior) than at an academic center. However, for elective procedures (lots of cath, angioplasty, CABG, spine surgery, low risk prostate) — I really, really have to wonder whether the risks and benefits to intervene (and generate $$$) is provided to the patient in the most honest way. Although the outcome is good — the question of whether or not you even needed the intervention — and where you’ll get an honest answer on that, is a whole other story. At least at some academic centers, there will be people conducting trials on said intervention, and whether or not it helps.

Doug S.

“This is a teaching hospital; you’re here to learn. We could call it a learning hospital, but that would scare the patients.” — ‘Gideon’s Crossing’

Matt

Maybe people like going to the expensive, prestige hospitals because they feel like, if things go wrong, they are allowed to complain. Also, the hospital would want to keep these high-paying customers so the customer service may be better.

I’d say the patients are perfectly rational. They don’t have good information on quality of healthcare, so they use proxies like prestige and price. As long as there’s a non-negligible positive correlation between these proxies and quality, what patients are doing is perfectly rational, especially since there are good reasons to be very risk-averse with healthcare.

Or are you saying the correlation between quality of healthcare and prestige/price as averaged over all healthcare providers is negative or very definitely exactly zero? I seriously doubt that.

Why do you think that going to high-status hospitals despite the facts is caused by desire to associate with high status, rather than stubborn inability to change one’s visceral opinion about quality of service in response to evidence? The latter looks more plausible to me, is there a fact to change my mind on that? Nontrivial evidence isn’t believed, people may ostensibly agree with it, but make decisions on a cherished gut feeling that wasn’t moved.

Tyrrell McAllister

I confess I haven’t read the article, so maybe I missed something. But what justifies your belief here?

Yes patients want prestigious docs and hospitals, and they may believe that high status docs are healthier, but I doubt that belief causes their demand; causation most likely goes the other way.

I think that I as a consumer rely on a general rule to the effect of “more expensive –> better quality”, especially in fields like medicine where, relative to other services, I would expect the wealthy to care more about actual effectiveness. Even if I’m wrong to expect that the wealthy think that way, or about the implication “more expensive –> better quality” in general, still this belief would influence my buying choices. In the aggregate, this would add to the demand of more-expensive hospitals. So the additional cost of some hospitals would really be due to a perception that they provide better service, not to my desire to affiliate with high-status docs.

Certainly status could explain why one hospital, rather than another, became more expensive in the first place. But once it is more expensive, I would expect patients’ desire for better care to keep it that way, even in the absence of any evidence besides the price that the care there is better.

Grant

I’m also skeptical that these studies are really all that accurate.

How much of the data is self-reported by hospitals? What if their reporting procedures are different? Are they controlling for all the relevant variables? What if the people in the more prestigious hospital tend to be sicker than others? I’d bet they tend to be older, since older people tend to be wealthier and more able to afford expensive medicine. How well can they control for the severity of the conditions?

I just can’t see really sick people caring about prestige. All the really sick people I’ve been around didn’t. They just wanted to get better, and to get better as quickly as possible.

I agree with Tomasz. There is obviously some correlation between prestige and quality of care, e.g. most people don’t go to witch doctors and faith healers. I can believe that this correlation is very low, because people do prefer to associate with others of higher status and are willing to pay for this privilege. What I find much more difficult to accept is that they would risk their own health to do so.

One problem that I’ve run into myself is that it is very hard for a layman to get a hold of data on health outcomes (for procedures or hospitals).

Constant

Constant, your theory that everything government touches is “strange” seems too weak to be of much use.

It is not a theory but a reminder that the economy is not happening in laboratory conditions. Physicists isolate what they’re studying very carefully from uncontrolled variables. Economists, understandably, cannot do this, but for this reason they should be mindful of them. I did not notice any manifestations of such mindfulness. On the contrary: a reminder to be mindful has been rejected as not “of much use”.

The theory that people seek connections with high status people leads to lots of concrete expectations.

Maybe, maybe not. Look at what people are moving in the direction of to a degree that is not accounted for by your initial model, label it “high status”, and voila, you have your “concrete expectation” that people are moving in that direction.

Constant

Explanation 2 basically asserts that Distortion A causes Distortion B with no description of the actual causal mechanism. Even if it’s correct, it doesn’t actually explain anything until more detail is provided.

I wasn’t trying to provide a competing explanation, I was warning Mr. Hanson against using the medical sector of all sectors as a test case for his novel ideas. He notices that people don’t do what one would normally expect in a regular market: prefer the cheaper over the more expensive (for a given level of quality) and choose the better over the worse (for a given price). But this is precisely the sort of departure one should expect in response to government interference that makes it extremely difficult compare prices and compare quality. It’s difficult even to know the price of the procedure one is about to receive. Doctors certainly are not eager to share it with you, and even if they did, you get multiple bills (or your insurance does) from various providers – not just the doctor but the hospital and the anesthesiologists, for instance. You receive one bill, you pay it off, and you think you’re done, but then you receive another, and another. You don’t know it’s all paid off until you stop receiving bills. And the bills are incomprehensible, and some of the items are outrageous – hundreds of dollars just to lie semi-conscious in a room for a couple of hours after surgery, for example. This is nothing like a typical capitalist market sector. Of course it’s hard for people to act as a microeconomist would normally expect. And I haven’t even mentioned the shielding effect of insurance (which is strongly encouraged by tax policy) on all this. As far as reputation, Beth Israel has a fantastic reputation, thought of very highly (I live in the area), whereas I have no such impression of Mass. General, so the notion that Beth Israel is lower status than Mass. General strikes me as being nothing other than an arbitrarily inserted presupposition to fit with the observed difference in payments. Just find the highest-paid hospital, call it “high status”, and voila, you have your explanation.

“One influential researcher found that Beth Israel’s overall mortality rate was lower in 2005 than the mortality rates at both the Brigham and Mass. General, but the hospital and its doctors still earn 15 percent to 20 percent less for the same work. ”

Does the study control for the complexity of procedures performed or the prior health of the patients being treated? Name brand medical centers often take care of patients with far more complex medical problems than your typical hospital. Lower-tier hospitals even transfer difficult cases into the hands of top-tier centers — and in many cases hand over complete train-wrecks to top centers in hopes that they’ll be able to clean things up. Looking at mortality rates alone is misleading at best.

“State health officials have tried to encourage women like Dahl to reconsider their flight to Boston, pointing out in a 2003 study that community hospitals are generally just as reliable as teaching hospitals for normal births.”

The study refers only to “normal” births. Of course, it’s impossible to know in advance whether you will have a “normal” birth. That’s why you consider going to a well-known hospital. For example, what if your baby needs emergency treatment upon delivery and the community hospital is not adequately staffed to provide it? You generally don’t have a heck of a lot of time. Are you really willing to roll the dice on the well-being of your baby?

There’s no doubt that one typically has to pay a premium to get treatment at top-tier medical centers (at the same time, these centers are not as much in the habit of denying patient care because of insurance reimbursement issues as a private practice might be). There’s also no doubt that name brand medical centers are far from perfect. I can’t tell what, if any, premium you should be paying. But to cite some dubious studies that leaves out valuable information is highly misleading.

This is a blog on why we believe and do what we do, why we pretend otherwise, how we might do better, and what our descendants might do, if they don't all die.